Fraud versus abuse
Medicare.gov defines fraud and abuse as follows:
- “Medicare fraud happens when Medicare is billed for services or supplies you never got.”
- “Abuse happens when doctors or suppliers don’t follow good medical practices, which leads to unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.”
How to report fraud and abuse
Both Medicare fraud and abuse should be reported to the Office of the Inspector General or Centers for Medicare & Medicaid Services.
HHS Office of Inspector General
Online: Report Fraud Online
Mail: HHS Tips Hotline
P.O. Box 23489
Washington, DC 20026-3489
Centers for Medicare & Medicaid Services
Mail: Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044
What to report
Concerns that should be reported include:
- Billing services that were not provided, including billing for more services than were provided
- Upcoding or selecting CPT codes based on reimbursement rather than services rendered
- Services provided are not medically necessary, including providing more treatment than necessary
- Wasteful spending
The Office of the Inspector General has several videos for provider compliance training online. These videos have a target audience of physicians; however, you may find some helpful information as well.
See also this resource created by the Medicare Learning Network about Medicare Fraud and Abuse.
See also, False Claims Act.
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